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Thromb Haemost 2000; 84(03): 442-448
DOI: 10.1055/s-0037-1614042
Commentary
Schattauer GmbH

An Alloantibody Recognizing the FVIII A1 Domain in a Patient with CRM Reduced Haemophilia A due to Deletion of a Large Portion of the A1 Domain DNA Sequence

Masaru Shibata
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Midori Shima
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Shogo Morichika
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
John McVey
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Edward G. D. Tuddenham
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Ichiro Tanaka
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Hiroshi Suzuki
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Keiji Nogami
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Yohko Minamoto
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Takaaki Hato
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Evgueni L. Saenko
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Dorothea Scandella
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
,
Akira Yoshioka
1   From the Department of Pediatrics, Nara Medical University, Kashihara, Nara; Department of the Internal Medicine I, School of Medicine, Ehime University, Ehime, Japan; Haemostasis Research Group, MRC Clinical Sciences Centre, Royal Postgraduate Medical School, London, U.K.; Holland Laboratory, American Red Cross, Rockville, MD, USA
› Author AffiliationsWe wish to thank Dr J. C. Giddings for his helpful suggestions.
Further Information

Publication History

Received 20 January 2000

Accepted after resubmission 14 April 2000

Publication Date:
14 December 2017 (online)

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Summary

We report the development of a FVIII inhibitor in a patient with severe, cross reacting material reduced (CRMR) haemophilia A. The level of Factor VIII antigen (FVIII:Ag) measured by ELISA using anti- C2 monoclonal and alloantibodies was 1.9 U/dl. This baseline FVIII:Ag level was increased to 8.3 U/dl after administration of DDAVP. The anti-FVIII inhibitor titer was 2.9 Bethesda U/ml. DNA analysis showed a large deletion of the FVIII gene from exon 4 to 7, corresponding to amino acid residues 111-317 included within the A1 domain. The size of the gene deletion was approximately 28 kb. 5' and 3' breakpoints were identified by sequencing in intron 3 and intron 7, respectively. FVIII mRNA was detected in the patient’s peripheral lymphocytes and the deletion spanning exon 4 to 7 was confirmed at the RNA level. Immunoprecipitation experiments using 125I labeled A1, A2 and light chain demonstrated that the inhibitor reacted only with the 54 kDa A1 domain. The inhibitor activity was more than 95% neutralized by A1 domain polypeptide. Our findings suggest a close relationship between the inhibitor epitope and the specific gene deletion with regard to the pathogenesis of the inhibitor in this patient.

Key words

Haemophilia A - inhibitor - A1 domain - gene deletion - factor VIII - cross-reacting material reduced
 

  • References

  • 1 Lazarchick J, Hoyer LW. Immunoradiometric measurement of the factor VIII procoagulant antigen. J Clin Invest 1978; 62: 1048-52.
    CrossrefPubMedGoogle Scholar
  • 2 Peake IR, Bloom AL, Giddings JC, Ludlam CA. An immunoradiometric assay for procoagulant VIII antigen: results in haemophilia, von Willebrand’s disease and fetal plasma and serum. Br J Haematol 1979; 42: 269-81.
    CrossrefPubMedGoogle Scholar
  • 3 Denson KWE, Briggs R, Haddon ME, Barrett R, Cobb K. Two types of haemophilia (A+ and A−): a study of 48 cases. Br J Haematol 1969; 17: 163-71.
    CrossrefPubMedGoogle Scholar
  • 4 Hoyer LW, Breckenridge RT. Immunologic studies of antihemophilic factor (AHF, factor VIII): cross-reacting material in a genetic variant of haemophilia A. Blood 1968; 32: 962-71.
    PubMedGoogle Scholar
  • 5 Gitschier J, Wood WI, Goralka TM, Wion KL, Chen EY, Eaton DH, Vehar GA, Capon DJ, Lawn RM. Characterization of the human factor VIII gene. Nature 1984; 312: 326-30.
    CrossrefPubMedGoogle Scholar
  • 6 Toole JJ, Knopf JL, Wozney JM, Sultzman LA, Buecker JL, Pittman DD, Kaufman RJ, Brown E, Shoemaker C, Orr EC, Amphlett GW, Foster WB, Coe ML, Knutson GJ, Fass DN, Hewick RM. Molecular cloning of a cDNA encoding human antihaemophilic factor. Nature 1984; 312: 342-7.
    CrossrefPubMedGoogle Scholar
  • 7 Wood WI, Capon DJ, Simonsen CC, Eaton DL, Gitschier J, Keyt B, Seeburg PH, Smith DH, Hollingshead P, Wion KL, Delwart E, Tuddenham EGD, Vehar GA, Lawn RM. Expression of active human factor VIII from recombinant DNA clones. Nature 1984; 312: 330-7.
    CrossrefPubMedGoogle Scholar
  • 8 Vehar GA, Keyt B, Eaton D, Rodriguez H, O'Brien DP, Rotblat F, Oppermann H, Keck R, Wood WI, Harkins RN, Tuddenham EGD, Lawn RM, Capon DJ. Structure of human factor VIII. Nature 1984; 312: 337-42.
    CrossrefPubMedGoogle Scholar
  • 9 Eaton D, Rodriguez H, Vehar GA. Proteolytic processing of human factor VIII. Correlation of specific cleavages by thrombin, factor Xa and activated protein C with activation and inactivation of factor VIII coagulant activity. Biochemistry 1986; 25: 8343-7.
    CrossrefPubMedGoogle Scholar
  • 10 Hoyer LW, Scandella D. Factor VIII inhibitors: Structure and function in autoantibody and haemophilia A patients. Semin Hematol 1994; 31: 1-5.
    PubMedGoogle Scholar
  • 11 Fulcher CA, Mahoney SdeG, Robert JR, Kasper CK, Zimmerman TS. Localization of human factor VIII inhibitor epitopes to two polypeptide fragments. Proc Natl Acad Sci USA 1985; 82: 7728-32.
    CrossrefPubMedGoogle Scholar
  • 12 Scandella D, Mahoney SdeG, Mattingly M, Roeder D, Timmons L, Fulcher CA. Epitope mapping of human factor VIII inhibitor antibodies by deletion analysis of factor VIII fragments expressed in Escherichia coli . Proc Natl Acad Sci USA 1988; 85: 6152-6.
    CrossrefPubMedGoogle Scholar
  • 13 Scandella D, Mattingly M, Mahoney SdeG, Fulcher CA. Localization of epitopes for human factor VIII inhibitor antibodies by immunoblotting and antibody neutralization. Blood 1989; 74: 1618-26.
    PubMedGoogle Scholar
  • 14 Scandella D, Mattingly M, Prescott R. A recombinant factor VIII A2 domain polypeptide quantitatively neutralizes human inhibitor antibodies which bind to A2. Blood 1993; 82: 1767-75.
    PubMedGoogle Scholar
  • 15 Foster PA, Fulcher CA, Houghten RA, Mahoney SdeG, Zimmerman TS. Localization of the binding regions of a murine monoclonal antifactor VIII antibody and a human antifactor VIII alloantibody. J Clin Invest 1988; 82: 123-8.
    CrossrefPubMedGoogle Scholar
  • 16 Prescott R, Nakai H, Saenko EL, Scharrer I, Nilsson IM, Humphires JE, Hurst D, Bray G, Scandella D. Recombinate and Kogenate Study Groups. The inhibitor antibody response is more complex in haemophilia A patients than in most nonhaemophiliacs with factor VIII autoantibodies. Blood 1997; 89: 3663-71.
    PubMedGoogle Scholar
  • 17 Antonarakis SE, Rossiter JP, Young M, Horst J, de Moerloose P, Sommer SS, Ketterling RP, Kazazian Jr HH, Negrier C, Vinciguerra C, Gitschier J, Goossens M, Girodon E, Ghanem N, Plassa F, Lavergne JM, Vidaud M, Costa JM, Laurian Y, Lin S-W, Lin S-R, Shen M-C, Lillicrap D, Taylor SAM, Windsor S, Valleix SV, Nafa K, Sultan Y, Delpech M, Vnencak-Jones CL, Phillips JA, Ljung PCR, Koumbarelis E, Gialeraki A, Mandalaki T, Jenkins PV, Collins PW, Pasi KJ, Goodeve A, Peake I, Preston FE, Schwartz M, Schiebel E, Ingerslev J, Cooper DN, Millar DS, Kakkar VV, Gianelli F, Naylor JA, Tizzano EF, Baiget M, Domenech M, Altisent C, Tusell J, Beneyto M, Lorenzo JI, Gaucher C, Mazurier C, Peerlinck K, Matthijs G, Cassiman JJ, Vermylen J, Mori PG, Acquila M, Caprino D, Inaba H. Factor VIII gene inversions in severe haemophilia A: results of an international consortium study. Blood 1995; 86: 2206-12.
    PubMedGoogle Scholar
  • 18 Schwaab R, Brackmann HH, Meyer C, Seehafer J, Kirchgesser M, Haack A, Olek K, Tuddenham EGD, Oldenburg J. Haemophilia A: mutation type determines risk of inhibitor formation. Thromb Haemost 1995; 74: 1402-6.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Hardisty RM, MacPherson JC. A one-stage factorVIII (Anti-haemophilic globulin) assay and its use on venous and capillary plasma. Thromb Diath Haemorrh 1962; 07: 215-28.
    PubMedGoogle Scholar
  • 20 Suzuki H, Shima M, Arai M, Kagawa K, Fukutake K, Kamisue S, Nakai H, Morichika S, Tanaka I, Inoue M, Gale K, Tuddenham EGD, Yoshioka A. Factor VIII Ise (R2159C) in a patient with mild haemophilia A, an abnormal factor VIII with retention of function but modification of C2 epitopes. Thromb Haemost 1997; 77: 862-7.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Kasper CK, Aledort LM, Counts RB, Edson JR, Frantatoni J, Green D, Hampton JW, Hilgartner MW, Lazerson J, Levine PH, McMillan CW, Pool JG, Shapiro SS, Shulman NR, van Eyes J. A more uniform measurement of factor VIII inhibitors. Thromb Diathes Haemorrh 1975; 34: 869-871.
    PubMedGoogle Scholar
  • 22 Mannucci PM, Ruggeri ZM, Pareti FI, Capitanio A. 1-deamino-8-Darginine vasopressin: A new pharmacological approach to the management of haemophilia and von Willebrand’s disease. Lancet 1977; 01: 869-72.
    PubMedGoogle Scholar
  • 23 Thompson AR, Murphy MLP, Liu M, Saenko EL, Healey JF, Lollar P, Scandella D. Loss of tolerance to exogenous and endogenous factor VIII in a mild haemophilia A patient with an Arg593 to Cys mutation. Blood 1997; 90: 1902-10.
    PubMedGoogle Scholar
  • 24 Marchalonis JJ. An enzymic method for the trace iodination of immunoglobulins and other proteins. Biochem J 1969; 113: 299-305.
    CrossrefPubMedGoogle Scholar
  • 25 Foster PA, Fulcher CA, Houghten RA, Mahoney SdeG, Zimmerman TS. Localization of the binding regions of a murine monolonal anti-factor VIII antibody and a human anti-factor VIII alloantibody, both of which inhibit FVIII procoagulant activity, to amino acid residues threonine351-serine365 of the factor VIII heavy chain. J Clin Invest 1988; 82: 123-8.
    CrossrefPubMedGoogle Scholar
  • 26 Morichika S, Shima M, Kamisue S, Tanaka I, Imanaka Y, Suzuki H, Shibata H, Pemberton S, Gale K, McVey J, Tuddenham EGD, Yoshioka A. Factor VIII gene analysis in Japanese CRM-positive and CRM-reduced haemophilia A patients by single-strand conformation polymorphism. Br J Haematol 1997; 98: 901-6.
    CrossrefPubMedGoogle Scholar
  • 27 Jurka J, Klonowski P, Dagman V, Pelton P. CENSOR-a program for identification and elimination of repetitive elements from DNA sequences. Comput Chem 1996; 20: 119-21.
    CrossrefPubMedGoogle Scholar
  • 28 Southern EM. Detection of specific sequences among DNA fragments separated by gel electrophoresis. J Mol Biol 1975; 98: 503-17.
    CrossrefPubMedGoogle Scholar
  • 29 Truett MA, Blacher RW, Burke RL, Caput D, Chu C, Dina D, Hartog K, Kuo CH, Masiarz FR, Merryweather JP, Najarian R, Pachl C, Potter SJ, Puma J, Quiroga M, Rall LB, Randolph A, Urdea MS, Valenzuela P, Dahl HHM, Favalaro J, Hansen J, Nordfang O, Ezban M. Characterization of the polypeptide composition of human factor VIII:C and the nucleotide sequence and expression of the human kidney cDNA. DNA 1985; 04: 333-49.
    CrossrefPubMedGoogle Scholar
  • 30 Sanger F, Nicklen S, Coulson AR. DNA sequencing with chain-terminating inhibitors. Proc Natl Acad Sci USA 1977; 74: 5463-7.
    CrossrefPubMedGoogle Scholar
  • 31 Fay PJ, Coumans JV, Walker FJ. von Willebrand factor mediates protection of factor VIII from activated protein C-catalyzed inactivation. J Biol Chem 1991; 266: 2172-7.
    PubMedGoogle Scholar
  • 32 Kemball-Cook G, Tuddenham EGD. The factor VIII mutation database on the World Wide Web: The haemophilia A mutation, search, test and resource site. HAMSTeRS Update (version 3.0). Nucl Acid Res 1997; 25: 128-32.
    CrossrefPubMedGoogle Scholar
  • 33 Youssoufian H, Antonarakis SE, Aronis S, Tsiftis G, Phillips DG, Kazazian Jr HH. Characterization of five partial deletions of the factor VIII gene. Proc Natl Acad Sci USA 1987; 84: 3772-6.
    CrossrefPubMedGoogle Scholar
  • 34 Pipe SW, Morris JA, Shah J, Kaufman RJ. Differential interaction of coagulation factor VIII and factor V with protein chaperones calnexin and calreticulin. J Biol Chem. 273. 8537, 1998.
    PubMedGoogle Scholar
  • 35 Van de Water N, Williams R, Ockelford P, Browett P. A 20.7 kb deletion within the factor VIII gene associated with LINE-1 element insertion. Thromb Haemost 1998; 79: 938-42.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Schon EA, Rizzuto R, Moraes CT, Nakase H, Zeviani M, DiMauro S. A direct repeat is a hotspot for large-scale deletion of human mitochondrial DNA. Science 1989; 244: 346-9.
    CrossrefPubMedGoogle Scholar
  • 37 Fijnvandraat K, Turenhout EAM, van den Brink EN, ten Cate JW, van Mourik JA, Peters M, Voorberg J. The missense mutation Arg593→Cys is related to antibody formation in a patient with mild haemophilia A. Blood 1997; 89: 4371-7.
    PubMedGoogle Scholar
  • 38 Peerlinck K, Jacquemin MG, Arnout J, Hoylaerts MF, Gilles JG, Lavend’homme R, Johnson KM, Freson K, Scandella D, Saint-Remy JM, Vermylen J. Antifactor VIII antibody inhibiting allogeneic but not autologous factor VIII in patients with mild hemophilia A. Blood 1999; 93: 2267-73.
    PubMedGoogle Scholar